Q.
My question concerns how and when to communicate definite knowledge of early sexual abuse to a child or teen who may not remember incidents that others know occurred many years prior? So much is written about possible repressed memories. Is there anything written for parents and/or professionals about how best to handle known information, in the absence of memories?
Related, is there literature on follow-up of the effects of early childhood sexual abuse that was quickly and appropriately handled by caring adults?

A.
First, let me say up front that I don't consider myself an expert in the area of child sexual abuse. But, knowing what I know as a general adult psychiatrist, I would predict that experts in this area would differ considerably in answering your questions. First off, there is the problem of what you term definite knowledge of sexual abuse. How is that defined? Did someone actually witness the abuse, and is that person the primary source of information? Does that individual have any axe to grind in coming forth with that information--e.g., could he or she be trying to scapegoat another family member?

While erroneous concerns about child sexual abuse appear to be rare (see Oates et al, Child Abuse Negl 2000; 24:149-57), Oates at al found that in a series of 551 cases of suspected abuse, 43% were substantiated, 21% were inconclusive, and 34% were considered not to represent abuse. In three cases, the researchers concluded that allegations were made as a result of collusion between the child and the parent; in three cases, an innocent event was misinterpreted as sexual abuse. Eight cases were considered false allegations of sexual abuse. Now, please understand: I am not taking the position that sexual abuse of children is made up or simply the result of implanted memories--I am merely noting that it isn't always crystal-clear what definite knowledge of abuse really means.

That said, let's get to your question: suppose we absolutely, positively know a child has been the victim of sexual abuse, but the child does not remember the abuse. What should be done? In my view, a great deal depends on the child's clinical and overall presentation. If, like many victims of abuse, the child is symptomatic, that's one thing. If the child is totally nonsymptomatic, and appears in all respects to be a happy, healthy individual, that may be another (though I think the odds of the second scenario are quite low, if there has been significant abuse). If the child is, say, showing signs of post-traumatic stress disorder, depression, significant anxiety, severe personality disturbance, or dissociative symptoms, I would certainly want to get him or her into psychotherapy with an expert in childhood psychiatric disorders.

Such experts often disagree as to how active one should be in eliciting supposedly repressed memories--and this remains an area of considerable controversy. For details on this, I recommend the chapter on "Memory" in Dr. Jon G. Allen's book, "Coping With Trauma". There, Dr. Allen reminds us of the statement from the American Psychiatric Assocation: "A strong prior belief by the psychiatrist that sexual abuse or other factors are or are not the cause of the patient's problems is likely to interfere with appropriate assessment and treatment." (p. 119). I agree--and would add that the therapist is not a detective bent on discovering historical truth. The therapist's job is to "validate the significance of [the patient's] current experience and [his or her] need to make sense of that experience." (Allen, p. 120). As Dr. Allen notes, "It's fine to let sleeping dogs lie. More commonly, however, the dogs are not sleeping; they're howling and barking." When the latter is the case--e.g., the child or adolescent is experiencing flashbacks, nightmares, dissociative bouts, engaging in self-destructive behavior, etc--then I would face the issue of how much to dig for repressed memories, or to confront the child with definite knowledge of abuse

Other clinicians with more experience in these matters might well disagree. Regarding follow-up effects of early intervention in sexual abuse cases, I am not aware of any controlled studies of this. However, some interesting work has come out of the C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, at the University of Colorado School of Medicine in Denver. Grosz et al (Child Abuse Negl 2000 24:9-23) describe an early intervention program for child victims, ages 2-14 years, in which families participated in crisis counseling, individual treatment of the child, support groups, etc.

These authors concluded that many clients showed a positive outcome with this kind of intervention--but no control group or formal assessement measures were utilized, limiting the strength of the conclusions. From other work with PTSD victims, however, we do have reason to believe that early intervention may help reduce subsequent complications. For more information, you may want to contact Dr. Grosz in the Department of Pediatrics, University of Colorado.